Lateral collateral ligament reconstruction using a semitendinosus graft.

We evaluated 13 reconstructions of the lateral collateral ligament (LCL) of the knee associated with a reconstruction of the ACL (n=6) and PCL (n=7). In all cases the LCL was reconstructed using a semitendinosus tendon graft through a tunnel in the fibular head and fixed in anatomical insertion of LCL at lateral femoral condyle. Patients were evaluated using the IKDC form. Lateral joint opening and posterior tibial translation were studied by radiographic stress views. The follow-up average was of 60 months (38-93). In the ACL group five patient were symptoms free while one reported moderate pain after strenuous activity. The lateral stress radiographs showed lateral joint opening of 0-2 mm in five knees, and 3-5 mm in one. In the PCL group four patients were symptom free while three complained mild to moderate pain or swelling. Lateral joint opening was 0-2 mm in six knees and 3-5 in one. External rotation at 30 degrees of flexion was 10 degrees in one and between 0-5 degrees in the remainder. Eleven of 13 patients returned to their preinjury level and two returned to one level lower. These findings indicate that the LCL can be successfully reconstructed with a free ST graft at the time of ACL or PCL reconstruction.

Effect of tourniquet use on activation of coagulation in total knee replacement.

Total knee replacement often is performed with tourniquet application. The advantages of a dry field, including fixation, are well known, but it still is debatable if tourniquet application increases deep vein thrombosis. Measurement of coagulation markers is a well accepted method of studying thrombogenesis activation intraoperatively and postoperatively. Twenty patients undergoing total knee replacement with subarachnoid anesthesia were assigned randomly to two groups: either with tourniquet application (Group I) or without tourniquet application (Group II). There were no differences between patients in the two groups in terms of age, gender, diagnosis (all had osteoarthritis), operative time, and total (intraoperative and postoperative) blood loss. Markers for thrombin generation and fibrinolysis were measured. Blood samples were drawn at four times: baseline before the operation; after bone cuts; after cement fixation (Group II) or 2 minutes after tourniquet deflation (Group I); and 1 hour after surgery. Markers of thrombin generation and fibrinolysis showed a significant increase from baseline in all the patients. In Group II these markers started to increase during surgery, whereas in Group I the increase occurred at the end of the procedure when the tourniquet was deflated. The total amount of thrombin generation was significantly higher in Group II (without tourniquet), whereas fibrinolysis was significantly greater in Group I. Total knee replacement is accompanied by a hypercoagulative state with or without the use of a tourniquet, but it seems to be higher when the tourniquet is not used. In addition, tourniquet application may increase fibrinolysis.

Procedure-dependence and tissue factor-independence of hypercoagulability during orthopaedic surgery.

The increased risk for deep vein thrombosis (DVT) after orthopaedic surgery has been well documented as well as hypercoagulable state during both total hip arthroplasty (THA) and total knee replacement (TKR). To investigate the influence of the surgical procedure [posterolateral (PL) or lateral (L) approach for THA, use of tourniquet (TQ) or not use of TQ for TKR] on the hypercoagulability and the role of extrinsic pathway activation and endothelial stimulation during orthopaedic surgery we have examined 40 patients (20 patients undergoing primary THA--10 with PL approach and 10 with L approach--and 20 patients undergoing TKR--10 with TQ application and 10 without TQ). Thrombin-antithrombin complexes (TAT), tissue factor (TF), tissue factor pathway inhibitor (TFPI), thrombomodulin (TM) and von Willebrand factor antigen (vWF:Ag) were analyzed before and during the orthopaedic surgery. During THA, TAT plasma levels increased more markedly in patients assigned to the L than PL approach (p <0.05); during TKR an elevation of TAT of higher degree (p <0.05) was observed when TQ was not applicated. Blood clotting activation was significantly (p <0.001) more relevant during THA than TKR. No changes in TF and vWF:Ag plasma levels were observed in all patients undergoing THA and TKR. TFPI plasma levels significantly (p <0.05) decreased 1 h after the end of the THA in group PL and group L, whereas they remained unaffected in the two groups of patients undergoing TKR. Similarly TM plasma levels significantly decreased during THA, but not during TKR. In conclusion, these results show that: 1) the site of surgical procedures and the type of approach affect the degree of hypercoagulability, 2) the blood clotting activation takes place in the early phases of orthopaedic surgery, without signs of extrinsic pathway and endothelial activation.